Medical record keeping as interactional accomplishment
Medical records are documents of tremendous social importance. They have been the subject of much medical and sociological research, in particular regarding validity, accessibility and readability. This paper uses Conversation Analysis to add an aspect to the understanding of medical records that has been missing so far, namely how medical records are produced as interactional accomplishments; specifically, how hospital staff members during meetings conversationally negotiate and reach conclusions, treatment recommendations, and other types of consequential decisions. The process involves four steps: assessing patients, interpreting implications, drawing conclusions, and dictating conclusions on tape. The key finding is that participants throughout the process orient towards a need for consensus, whilst at the same time acknowledging the doctors’ interactional leading roles. This insight can enhance our understanding of medical records in hospital settings as constructed and negotiated realities.
Keywords: health care communication, geriatrics, ethnomethodology, Conversation Analysis, dictation, medical records, decision-making, co-authorship, multidisciplinarity, interactional leadership
Published online: 25 August 2014
Antaki, Charles, Barnes, Rebecca, and Leudar, Ivan
Atkinson, Maxwell J. and Heritage, John
Beck Nielsen, Søren
Berg, Marc and Winthereik, Britt Ross
Boockvar, Kenneth S., Livote, E.E., Goldstein, N., Nebeker, J.R., Siu, A. and Fried, T.
Brown, Penelope and Levinson, Stephen C.
Collins, Sarah, Drew, Paul, Watt, Ian S. & Entwistle, Vikki A.
David, Gary C., Garcia, Angela Cora, Rawls, Anne Warfield & Chand, Donald
Garcia, Angela Cora, David, Gary C. & Chand, Donald
Greenhalgh, Trisha, Potts, Henry W.W., Wong, Geoff, Bark, Pippa, Swinglehurst, Deborah
Heath, Christian and Luff, Paul
1996 Documents and Professional Practice: ‘Bad’ Organisational Reasons for ‘Good’ Clinical Records. Proceedings of the Conference on Computer Supported Cooperative Work , Boston, 354–363. ACM Press.
Heritage, John and Watson, David R.
Heritage, John and Maynard, Douglas W.
Komter, Martha L.
Lisby, Marianne, Nielsen, Lars Peter, and Mainz, Jan
Luke, Kang-Kwong, Lam, Tai Pong, and Zhang, Wei
Meehan, Albert J.
Reiser, Stanley J.
Sacks, Harvey, Schegloff, Emanuel A. and Jefferson, Gail
Schegloff, Emanuel A.
Schegloff, Emanuel A., Jefferson, Gail, and Sacks, Harvey
Wibe, Torunn, Hellesø, Ragnhild, Slaughter, Laura, and Ekstedt, Mirjam
Zimmerman, Don H.
Cited by 2 other publications
Sterponi, Laura, Cristina Zucchermaglio, Francesca Alby & Marilena Fatigante
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